Future Commissioning of London HIV Prevention Services Project Steering Group

London HIV Prevention Mapping

This report was commissioned by the Association of Directors of Public Health (London) and written by Andrew Billington and Fraser Serle Paul Fraser Associates In February 2013 the Leaders’ Committee at London Councils recognised the shortcomings of the Pan London HIV Prevention Programme (PLHPP) approach to HIV prevention. In response, the Association of Directors of Public Health (ADPH) London, working with London Councils, designed the Future Commissioning of London HIV Prevention Services (FCLHPS) Project to oversee a London-wide needs assessment over the summer of 2013. The FCLHPS project included six work streams:

- Epidemiological review
- Evidence review update
- A Call for Evidence
- Stakeholder engagement
- Segmented insight research
- Mapping of current HIV prevention.

The overall findings of the needs assessment are published in the report: “HIV Prevention Needs Assessment for London” (November 2013). This report is the output of one of the six underpinning work streams, and focused on the mapping of current HIV prevention. ADPH London and London Councils will develop an options paper for a meeting of the leaders of the 33 councils in London, due to take place in November 2013. THE FUTURE COMMISSIONING OF HIV PREVENTION IN LONDON

London HIV Prevention Mapping

A REPORT FOR THE ASSOCIATION OF DIRECTORS OF PUBLIC HEALTH LONDON

October 2013

Andrew Billington, Fraser Serle

1. CONTEXT

In February 2013 the Leaders Committee at London Councils recognised the shortcomings of the Pan London HIV Prevention Programme (PLHPP) approach to HIV prevention. In response, Association of Directors of Public Health (ADPH) London, working with London Councils, designed the Future Commissioning of London HIV Prevention Services (FCLHPS) Project to oversee a London-wide needs assessment over the summer of 2013.

The FCLHPS project included six work streams:

- Epidemiological review
- Evidence review update
- A Call for Evidence
- Stakeholder engagement
- Segmented insight research
- Mapping of current HIV prevention

The overall findings of the needs assessment are published in the report, “HIV Prevention Needs Assessment for London” (November 2013). This report is the output of one of the six underpinning work streams and focused on the mapping of current HIV prevention. ADPH London and London Councils will develop an options paper for a meeting of the leaders of the 33 councils in London, due to take place in November 2013. 2. INTRODUCTION

Since April 2013 the responsibility for sexual health promotion and HIV prevention commissioning has sat with Local Authorities. This report describes a high level mapping of HIV prevention spend for London which includes spend on locally commissioned provision, pan-London commissioned provision, and nationally commissioned provision. HIV Prevention England (HPE), the national HIV prevention programme for England, aims to deliver a nationally coordinated programme of HIV prevention work with UK-based African people and with gay men/men who have sex with men (MSM). This programme will bring together campaigns, online services, local work and policy work.

Local Authorities are responsible for HIV prevention and sexual health promotion, open access genitourinary medicine and contraception services for all age groups. This includes services commissioned from general practice and pharmacy, such as long acting forms of contraception, chlamydia screening, and emergency hormonal contraception.

The HIV prevention mapping exercise endeavoured to:

- Map HIV prevention services for 2013–2014 commissioned through local authorities in London; and
- Map HIV prevention spend targeted towards London, as delivered by HPE.

The mapping does not attempt to map HIV prevention spend in London funded from non-statutory sector sources. HIV treatment and care, health services for prisoners, sexual assault referral centres, or other sexual health services commissioned by either NHS England or Clinical Commissioning Groups are not within the scope of this mapping exercise.

This mapping exercise took place between August and October 2013. 3. METHODOLOGY

The following methods were used:

- All Local Authority HIV commissioners and DsPH were requested to complete a survey identifying: (i) spend on HIV prevention activity for 2013–2014; (ii) population groups targeted; and (iii) interventions or programmes commissioned. Non-respondents or respondents who submitted incomplete returns were further contacted in an effort to obtain a complete picture of spend for London; and

- Data on the HPE programme was requested from to the Department of Health. This request was forwarded to the Terrence Higgins Trust (THT) as the HPE programme lead.

4. LIMITATIONS

The process of trying to identify and quantify local spend has highlighted considerable variations in the way Local Authorities categorise or define commissioned HIV programmes and services. It has also highlighted challenges in disaggregating spend on HIV prevention where this is included in contracts for broader interventions or services.

In their submissions, Local Authorities did not separately identify spend on primary and secondary HIV prevention interventions, and social care and support services/programmes for people living with HIV (PWHIV) were also included (the latter often having elements of secondary HIV prevention). As a consequence, the mapping includes spend on interventions which are primarily focused on social care and support for PWHIV, rather than HIV prevention itself.

There are also primary HIV prevention components within Locally Enhanced Services (LES), Genito-Urinary Medicine (GUM) and Contraception and Sexual Health (CaSH) contracts. Respondents reported it to be difficult to identify the primary HIV prevention components of these services and consequently the related spend, with much HIV prevention activities, is integrated into services addressing the wider sexual health needs of service users.

Some Local Authorities have integrated HIV prevention spend and activity into other areas of health, for example, teenage pregnancy, sexual health, and substance misuse. These Local Authorities found it difficult to disaggregate this spend.

For these reasons, figures in this report must be treated with considerable caution and only regarded as indicative. It is likely that they overestimate spend on HIV prevention due to the inclusion of Local Authority spend on a wider range of services of which HIV prevention is one element. 5. FINDINGS

HIV prevention services in London are currently funded via: (i) Local Authorities’ public health grant to fund local activity; (ii) the PLHPP (which in turn is funded by Local Authority contributions from their public health grant, weighed according to each Local Authority’s share of prevalent infections); and (iii) the HPE programme, funded by the Department of Health.

Responses to the survey indicate that Local Authorities found it problematic to identify specific HIV prevention spend and activities. This may be partly a result of there being no agreed shared definition for what constitutes HIV prevention, or a common commissioner data set. Of the activity included in this mapping, the current PLHPP and HPE programmes stand out as those areas/services that can be clearly defined as HIV prevention activity.

Based on the information provided the reported figure for total HIV prevention spend in London is approximately £12.5 million during 2013–2014.

Appendix 1 sets out the for results of the mapping in more detail:

- Table 1: HIV Prevention Mapping: top line spend against target groups; and
- Table 2: HIV Prevention Mapping: spend against interventions.

5.1 LOCAL AUTHORITIES

contentious, and concerns were raised as to the variance in commissioning expertise, There is a range of commissioning arrangements in London for HIV prevention. Whilst most Local Authorities commission individually, some maintain joint commissioning arrangements with other Local Authorities. Local Authority commissioned programmes for HIV prevention identified through this mapping have an estimated total spend of £10.5m.

Some Local Authorities do not make arrangements for specific primary HIV prevention commissioning and contracting, having integrated HIV prevention into other areas, most frequently sexual health services, but also blood borne virus, reduction/harm minimisation services and programmes. Therefore, most commissioned HIV prevention interventions are integrated HIV and sexual health and with other areas, for example, mental health and general health improvement.

Spend by local authority, where information has been supplied, demonstrates that:

- The largest spend by target population group is for people living with HIV, totalling approximately £3.8m; this figure represents spend primarily on secondary prevention and HIV social care and support services, rather than primary prevention;
- The second largest category of spend was for young people (approximately £1.9m);
- The spend on African communities is approximately £1.6 m;
- Spend on interventions or services targeting MSM at a local level amounts to approximately £795k although this is supplemented by London-wide activities through the PLHPP; and
- For a significant proportion of spend, the target population could not be readily specified in this way.

In terms of spend by type of intervention; condoms and HIV testing account for £959k and £843k respectively of identified spend. 5.2 PAN LONDON HIV PREVENTION PROGRAMME

Each London Local Authority currently contributes to this programme. The current PLHPP spend is £1.03m. There are four contracts that focus on delivering: (i) group work; (ii) health promotion interventions; (iii) counselling; and (iv) condoms, all targeting MSM. Individual Local Authority contributions are based on the Survey of Prevalent HIV Infections Diagnosed (SOPHID) figures. Whilst SOPHID data remains the best way to calculate “fair share” contributions by London Local Authorities to the PLHPP, there is a need to update these calculations based on the most recently available prevalence data. The current allocations are based on 2008 data.

5.3 HIV PREVENTION ENGLAND

The HPE programme is funded by the Department of Health for three years from 2012 to 2015. It is managed by THT, supported by a team of five sub-contractors drawn from the voluntary, public and private sectors:

- Black Health Agency For Equality;
- London School of Hygiene & Tropical Medicine;
- MBARC;
- NAM Publications; and
- Yorkshire MESMAC.

The government has committed the equivalent of £2.45m per year to HPE. It is planned to spend about 35% of this on campaign delivery and online services, 35% on local services, 15% on development and engagement work, and the remaining 15% on monitoring and evaluation. HPE report that £955k is spent with specific benefit to London, equivalent to about 39% of the total £2.45m.

HPE used the following indicators to determine where spend in London may be most beneficial:

- Diagnosed prevalence of HIV of > 2 per 1,000 population aged 15–59; and
- Number of individuals with a late diagnosis between 2008 and 2011 >50.

In addition, the population receiving care in the target area was analysed to determine whether the area was a priority for either black African or MSM investment or black African and MSM investment. This was calculated using a percentage indicator of >60% for either population. Where both populations were 40–59%, it was recommended that both were targeted.

Interventions are commissioned as follows:

- HPE MSM programme: targeting is done by risk behaviour and by the approach needed to reach the population taking that risk behaviour. The intervention commissioned is the one that evidence has shown is most effective for that behaviour and / or that population. This means that the setting is variable, as they have not commissioned by location. Many clinics, gay venues, saunas, etc., are being visited but this information is reported to HPE after the intervention has taken place; and

- HPE African programme: delivery of interventions is undertaken in a variety of settings frequented by Africans and include commercial venues, community centres, educational, faith, and non-health organisations (e.g. refugee groups) and clinics.

6. OBSERVATIONS

As a proportion of total spend identified in Appendix, including PLHPP spend and HPE spend, the majority of spend by target group is on PWHIV. However, the majority of this spend is on care and support services, which include elements of secondary prevention of HIV. Excluding spend on PWHIV from the total, the majority of spend is on MSM (17%) followed by African Communities (16%) and young people (16%). It should be noted that African people and MSM make up the majority of PWHIV living in London (34% and 47% respectively, taken from the Review of HIV Epidemiology in London for the Pan London HIV Prevention Needs Assessment, PHE, October 2013). Thus the majority of spend on HIV services in London is likely to be on services or interventions that are accessed by these groups.

The lack of detail on the types of interventions commissioned make it difficult to identify which are the most commonly commissioned. However, excluding spend on PWHIV, general sexual health interventions with young people (10%) and condom distribution (10%) account for the largest proportion of HIV prevention spend, with HIV testing ranking third (7%).

Figures supplied indicate that total spend on the HIV Prevention England programme is £2.45m of which £955,000 (39%) is spent in London; £290,474 (30%) of that is currently committed to local engagement activities.

Because of the challenges noted in this report associated with accurately identifying and quantifying spend on HIV prevention by Local Authorities, it is not possible to make any comment on comparative spend between Local Authorities nor to readily understand the extent to which spend reflects local need e.g. HIV prevalence rates. It is also not possible to make an assessment of the value of HPE activity in any Local Authority, until the post intervention activity monitoring data has been reported.

### APPENDIX 1.

#### Table 1: HIV Prevention Mapping: top line spend against target groups (£1,000's)

| | African Communities | MSM | Young People | Sex Workers | PWHIV | GUM Attendees | Unspecified | Other | Total | |----------------------|---------------------|-----|--------------|-------------|-------|---------------|-------------|-------|---------| | Total Borough Spend | 1627 | 795 | 1994 | 494.5 | 3817.5| 152 | 1564.5 | 38 | 10482.5 | | PLHPP Spend | | | | | | | | | 931 | | HPE Spend | 323 | 367 | | | | | | | 690 | | Total | 1950 | 2093| 1994 | 494.5 | 3817.5| 152 | 1564.5 | 38 | 12103.5 |

Note 1. HPE spend does not include spend on management co-ordination, development and engagement work and M and E

Note 2. PLHPP spend does not include management costs

#### Table 2: HIV Prevention Mapping: spend against interventions (£1,000's)

| | SH and HIV Primary Prevention General | SH and HIV Young People General | SH and HIV Prevention BME General | MSM General | Community Services | Condom Distribution | HIV Testing | HIV Testing Promotion | 1to1 and Group work | Social Marketing and Mass Media | Outreach | Testing | Sex Workers - Unspecified | Reducing Late Diagnoses | Primary and Secondary Prevention PWHIV | Unallocated or Unspecified | Total | |----------------------|--------------------------------------|---------------------------------|----------------------------------|-------------|--------------------|--------------------|-------------|------------------------|---------------------|-----------------------------|----------|---------|--------------------------|--------------------------|-----------------------------|-----------------------------|---------| | Total Borough Spend | 125 | 1261 | 574.5 | 498 | 61.5 | 959 | 843.5 | 99.5 | 303.5 | 155 | 554 | 96.5 | 308.5 | 132.5 | 3903.5 | 571 | 10882.5 | | PLHPP Spend | | | | | | | | | | | | | | | | | 931 | | HPE Spend | | | | | | | | | | | | | | | | | 690 | | Total | 125 | 1261 | 574.5 | 498 | 61.5 | 1185 | 843.5 | 99.5 | 717.5 | 555 | 864 | 96.5 | 308.5 | 132.5 | 3903.5 | 862 | 12103.5 |

Note 1. HPE spend does not include spend on management co-ordination, development and engagement work and M and E

Note 2. Primary and Secondary Prevention PWHIV includes all monies spent on PWHIV - majority will be treatment, care and support with minority prevention component